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NR 302-Week 4 Edapt Vital Signs
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Week 4 Edapt- NR 302Vital Signs
Pulse Rate
Pulse rate normally varies with age, being rapid (not slow) in infancy and childhood
and decreasing (not increasing) with age.
The rate also varies with gender. After puberty, females (not males) have a slightly faster rate
than males (not females).
If a client has a high or low vital sign finding, first verify the abnormal finding by assessing the apical
pulse for a full minute.
Notifying the healthcare provider would occur after the finding is verified and a focused assessment
completed. The findings should be documented after the focused assessment is completed. Information
about the client’s previous heart rate and rhythm can be found in the electronic health record (EHR), so
there is no reason to contact the client’s family for additional information.
Abnormal Assessment Findings
Physiology of Blood Pressure
The diastolic reading, or bottom number, is the pressure in the arteries when the ventricles are at
rest. The difference between systolic and diastolic pressure is the “pulse pressure.” The pressure in the
aortic arch is not measured with blood pressure. The pressure during heart contraction is “systolic”
pressure.
The first sound is phase 1 of Korotkoff sounds and reflects the systolic number.
The diastolic pressure is marked when the sound can no longer be heard.
Pulse pressure is the difference between the systolic and diastolic blood pressure measurements.
An auscultatory gap is an absence of sound suggesting reduced peripheral blood flow.
What Are Vital Signs?
A temperature of 95.1 °F (35.1 °C) is considered hypothermia (not hyperthermia).
A heart rate of 110 beats/min in an adult is documented as tachycardia (not bradycardia).
Respirations of 20 breaths per min in an adult are normal (not tachypnea).
Blood pressure of 144/98 mm Hg in an adult is considered hypertension (not hypotension).
, When Should Vital Signs Be Taken?
The examiner should take vital signs:
upon admission
as ordered by a provider
before and after surgical or diagnostic procedures
before and after certain medications, especially those that affect cardiovascular, respiratory, and
temperature function
when the client's general condition changes
before and after certain interventions, such as when a client ambulates for the first time or after tracheal
suctioning
Temperature
Body temperature is the job of the hypothalamus, which is located in the brain and forms the floor and
part of the lateral wall of the third ventricle.
The hypothalamus helps maintain a balance between heat lost and heat produced.
Temperature is documented in Fahrenheit (F) or Celsius (C), depending on geographic setting and
facility policy.
Pulse
Pulse is a rhythmic beating or vibrating movement in the body. It signifies the regular, recurrent
expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection
of the blood from the left ventricle of the heart. Each pulse beat corresponds to a contraction of the
heart. The adult pulse rate is normally between 60 and 100 beats per minute with the approximate
average being 80.
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